Employer health insurance
Employers can offer two types of group health plans: fully insured or self-insured plans.
Fully insured
For fully insured plans, employers pay a fixed premium to a third-party commercial insurance carrier that covers the medical claims. The New Hampshire Insurance Department regulates fully insured plans since they are an insurance “product” sold in New Hampshire.
Self-Insured Health Care Plans
With “self-insured” or “self-funded” health insurance plans, the employer covers the medical costs and takes on the risks. However, the employer may have an insurance company manage the plan, handle paperwork, and bill for premiums. This can make it appear like a “fully insured” plan, with the insurance company’s name appearing on the card and paperwork. To determine if your plan is self-insured, you should speak with the person at your workplace responsible for insurance. This is important because the state’s insurance department does not regulate self-insured plans, as they are not considered an insurance “product” sold in the state. Instead, they are governed by the Department of Labor, and while they must abide by federal laws (like ERISA), they do not have to comply with state mandates. An example is “Connor’s Law,” a NH bill that requires insurance companies to cover specific Autism therapies, such as Applied Behavior Analysis (ABA) therapy. Since Connor’s Law is a state law, it only applies to insurance products sold in NH.
Individual health insurance
An individual can purchase an individual health plan to cover a single person or a family. If self-employed, if an employer does not offer insurance, or offers insurance that is not affordable, consider the following options:
- Plans can be purchased through the NH Marketplace. You must do so during the “Open Enrollment” period from November 1st to January 15th of the following year. There are “Special Enrollment Periods” that apply if coverage is lost, such as due to a change in employment or no longer qualifying for Medicaid. Some individuals will qualify for cost-sharing reductions or subsidies, making their plans more affordable. You can view plans on Healthcare.gov or the NH Insurance Department’s webpage.
- Plans can also be purchased through a health insurance company that sells plans in New Hampshire. The New Hampshire Insurance Department regulates these plans and maintains a list of licensed companies on its website.
- For assistance accessing the marketplace, you can reach one of the navigators at Health Market Connect.
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What you should know about your health plan
Understanding your health insurance plan and how to use it:
- Know what you may have to pay. Review your Summary of Benefits to see which expenses are covered under your plan and costs you may need to pay (copays, coinsurance, deductibles). Contact your insurance provider if you have questions.
- Find out which providers are in your plan’s network. Be sure to check if all of your current doctors are in network. If they are not, identify your plan’s policy and cost regarding the use of out-of-network providers.
- Learn about prescription drug coverage. What medications are on the formulary? How much is allowed at renewal? What pharmacies are in-network? Is mail order an option?
- Identify any referral and prior authorization requirements. Some plans may not cover the cost of the services without a referral or prior authorization.
- Know the enrollment period and plan renewal date. (If you met your deductible in June, scheduling other procedures before the plan renews when possible makes sense.)
- Many health insurance plans provide an “Explanation of Benefits” (EOB) after you visit the doctor or have an appointment. The EOB has specific information about your plan, appointment, and what you and the plan will pay. If you find an error, call your insurance company and wait for the provider’s bill. If you find a difference between the amount owed on an EOB and a bill, follow up with both the insurance company and the billing department.
- Rest assured, you have the right to appeal a denial of service or refusal to authorize service. There may be multiple levels of appeal available. Be aware of the timelines that apply.
- Inquire whether case or care management is an available service from your plan.
What to do if insurance won’t pay
Private health plans may deny a claim. It will show on your EOB that it is your responsibility to pay. If this happens and you feel it is in error, seek clarification. Sometimes, it is as simple as resubmitting the claim to insurance.
Your insurance may also deny authorization for treatment. You may need to request a written denial to initiate the appeals process.
Consider filing an appeal if you receive a denial or authorization for a covered service. With every EOB, you should receive information on how to file an appeal if you disagree with the insurance company’s decision. You can also contact the insurance company directly and ask about the appeal process and timelines.
There are two levels of appeal: internal and external. Individual health plans typically have one level of internal appeal, and group plans have two.
When filing an appeal, do so in writing, keep copies of all correspondence, and be aware of any time limits. If you wait too long, you may not be able to appeal.
If you have a fully insured plan in New Hampshire, you can also ask the NH Insurance Department for help with an external appeal. Call the NH Insurance Department at (800) 852-3416.
If your group plan is self-funded by your employer, contact your employer’s human resource department for assistance.